Nursing administration

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Mr. Channabasappa.K.M
UNIT –VIII
CONTROLLING
1. QUALITY ASSURANCE- CONTINUOUS QUALITY IMPROVEMENT
Introduction
In the changing health care environment, concerns over quality of care are receiving
greater attention than ever before. As consumer become more knowledgeable as a result of
increased information available to them, much of the mystique surrounding health care is
being dissipated.
Quality management (QM) and quality improvement (QI) are the basic concepts
derived from the philosophy of total quality management (TQM). Now it is preferred to
use the term Continuous Quality Improvement (CQI) since TQM can never be achieved.
And the method of monitoring of healthcare for CQI is done with Quality Assurance (QA).
Definition
 ―Quality assurance is a judgment concerning the process of care based on the extent to
which that care contributes to valued outcomes.‖ -
Donabedian 1982
 ―Quality assurance is the measurement of provision against expectations with
declared intention and ability to correct any demonstrated weakness.‖
-Shaw
 ―Quality assurance is a management system designed to give maximum guarantee and
ensure confidence that the service provided is up to the given accepted level of
quality, the standards prescribed for that service which is being achieved with a
minimum of total expenditure.‖
-British Standards Institute
Quality assurance vs. Continuous quality improvement (Koch, 1993)
Quality improvement is not necessarily a replacement for existing quality assurance
activities, but rather an approach that broadens the perspectives on quality.
Quality assurance (QA) Quality Improvement (QI)
 Inspection oriented (detection)
 Reaction
 Correction of special causes
 Responsibility of few people
 Narrow focus
 Leadership may not be vested
 Problem solving by authority
 Planning oriented (prevention)
 Proactive
 Correction of common causes
 Responsibility of all people involved
with the work
 Cross- functional
 Leadership actively leading
 Problem solving by employees at all
levels

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Objectives
 To successfully achieve sustained improvement in health care, clinics need to design
processes to meet the needs of patients.
 To design processes well and systematically monitor, analyze, and improve their
performance to improve patient outcomes.
 A designed system should include standardized, predictable processes based on best
practices.
 Set Incremental goals as needed.
NASA Ames ResearchCenter Health Unit
 Public accountability- It provides evidence that the funds are being spend both
effectively resulting in optimum utilization of the resource resulting in operational
efficiency and efficiency of services provided.
 Management improvement- This is to provide quality assurance programme as a tool
for managerial problem solving. It includes identification of the problem in areas of
technical quality, efficiency, risk and patient satisfaction to assess its nature, causes
and taking effective actions to reduce or eliminate the identified problems.
 Facilitation of adoption of innovations- It includes evaluation of performance of
individuals professionals, preparation of appropriate criteria for assessment of
processes and outcome, exchange of information within and outside the organization,
and introduction of innovations with assessment of their impact on patient care
outcome, risk and satisfaction by using the patient as a unit for analysis.
Quality assurance whether in health or education had two main objectives:
 To provide technical assistance in designing and implementing effective strategies for
monitoring quality and correcting systemic deficiencies and
 To refine existing methods for ensuring optimal quality health care through an applied
research programme
(Decker, 1985 and Schroeder, 1984).
Purposes/ Need
 Rising expectations of consumer of services.
 Increasing pressure from national, international, government and other professional
bodies to demonstrate that the allocation of funds produces satisfactory results in
terms of patient care.
 The increasing complexity of health care organizations.
 Improvement of job satisfaction.

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 Highly informed consumer
 To prevent rising medical errors
 Rise in health insurance industry
 Accreditation bodies
 Reducing global boundaries.
Principles
 QM operates most effectively within a flat, democratic and organizational structure.
 Managers and workers must be committed to quality improvement.
 The goal of QM is to improve systems and processes and not to assign blame.
 Customers define quality.
 Quality improvement focuses on outcome.
 Decisions must be based on data.
According to W Edward Deming; (Deming’s 14 points)
 Crete consistency of purpose for improvement of product and service.
 Adopt the new philosophy
 Cease dependence on inspection to achieve quality.
 End the practice of awarding business on the basis of price tag.
 Improve constantly and forever the systems of production and service.
 Institute training on the job.
 Institute leadership.
 Drive out fear.
 Break down barriers between departments.
 Eliminate slogans, exhortations, and target for the workforce.
 Eliminate numerous quotas for the workforce and numerical goals of management.
 Remove barriers that rob people of pride and workmanship.
 Institute a vigorous programme of education and self-improvement for everyone.
 Put everyone in the company to work to accomplish the transformation.
Approaches
 General approach
 Specific approach
General approach: - It involves large governing or official bodies evaluating a person or
agencies‘ ability to meet established criteria or standard during a given time.
a) Credentialing- It is the formal recognition of professional or technical
competence and attainment of minimum standards by a person and agency.
Credentialing process has 4 functional components
 To produce a quality product
 To confirm a unique identity
 To protect the provider and public
 To control the profession

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b) Licensure- It is a contract between the profession and the state in which the
profession is granted control over entry into an exit from the profession and over
quality of professional practice.
c) Accreditation- It is a process in which certification of competency, authority, or
credibility is presented to an organization with necessary standards.
d) Certification
e) Charter- It is a mechanism by which a state government agency under state law
grants corporate state to institutions with or without right to award degrees.
f) Recognition- It is defined as a process whereby one agency accepts the
credentialing states of and the credential confined by another.
g) Academic degree
Specific approach: - These are methods used to evaluate identified instances of provider and
client interactions.
a) Audit- It is an independent review conducted to compare some aspect of quality
performance, with a standard for that performance.
b) Direct observation- Structured or unstructured based on presence of set criteria.
c) Appropriateness evaluation- The extent to which the managed care organization
provides timely, necessary care at right levels of service.
d) Peer review- Comparison of individual provider‘s practice either with practice by the
provider‘s peer or with an acceptable standard of care.
e) Bench marking- A process used in performance improvement to compare oneself
with best practice.
f) Supervisory evaluation
g) Self-evaluation
h) Client satisfaction
i) Control committees
j) Services- Evaluates care delivered by an institution rather than by an individual
provider.
k) Trajectory- It begins with the cohort of a person who shares distinguishing
characteristics and then follows the group going through the healthcare system noting
what outcomes are achieved by the end of a particular period
l) Staging- It is the measurement of adverse outcomes and the investigation of its
antecedence.
m) Sentinel- It involves maintaining of factors that may result in disease, disability or
complications such as;
 Review of accident reports
 Risk management
 Utilization review
Elements/ components
 According to Donabedian;
 Structure Element- The physical, financial and organizational resources
provided for health care.

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 Process Element- The activities of a health system or healthcare personnel in
the provision of care.
 Outcome Element- A change in the patient‘s current or future health that
results from nursing interventions.
According to Manwell, Shaw, and Beurri, there are 3A’s and 3E’s;
 Access to healthcare
 Acceptability
 Appropriateness and relevance to need
 Effectiveness
 Efficiency
 Equity
Standards
Standards are written formal statements to describe how an organization or
professional should deliver health service and are guidelines against which services can be
assessed. Kirk and Hoesing (1991) stated that standards are needed to;
 Provide direction
 Reach agreement on expectations
 Monitor and evaluate results
 Guide organizations, people and patients to obtain optimal results.
Standards are directed at structure, process, and outcome issues and guide the review of
systems function, staff performance, and client care. The organizations providing quality
indexes are;
•AHRQ –Agency for Healthcare Research and Quality
•IHI –Institute for Healthcare Improvement
•JCAHO –Joint Commission on Accreditation of Healthcare Organizations
•NAHQ –National Association for Healthcare Quality
•IOM –Institute of Medicine
•NCQA –National Committee for Quality Assurance
Areas of QA
The assurance in various key areas are
 Outpatient department- The points to be remembered are;
 Courteous behavior must be extended by all, trained or untrained personnel.
 Reduction of waiting time in the OPD and for lab investigations by creating
more service outlets.
 Provide basic amenities like toilets, telephone, and drinking water etc.
 Provision of polyclinic concept to give all specialty services under one roof.
 Providing ambulatory services or running day care centers.

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 Emergency medical services
Services must be provided by well trained and dedicated staff, and they should
have access to the most sophisticated life- saving equipment and materials,
and also have the facility of rendering pre- hospital emergency medical aid
through a quick reaction trauma care team provided with a trauma care
emergency van.
 In- patient services
Provide a pleasant hospital stay to the patient through provision of a safe,
homely atmosphere, a listening ear, humane approach and well behaved,
courteous staff.
 Specialty services
A high tech hospital with all types of specialty and super- specialty services
will increase the image of the hospital.
 Training
A continuous training programme should be present consisting of ‗on the job
training‘, skill training workshops, seminars, conferences, and case presentations.
Models of quality assurance
1. Donabedian Model (1985): It is a model proposed for the structure, process and outcome
of quality. This linear model has been widely accepted as the fundamental structure to
develop many other models in QA.

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Evaluate
outcome of
standards
and criteria
Identify
structure ,
standard and
criteria
Apply the process,
standards and
criteria
2. ANA Model: This first proposed and accepted model of quality assurance was given by
Long & Black in 1975. This helps in the self- determination of patient and family, nursing
health orientation, patient‘s right to quality care and nursing contributions.
3. Quality Health Outcome Model:
The uniqueness of this model proposed by Mitchell & Co is the point that there are
dynamic relationships with indicators that not only act upon, but also reciprocally affect the
various components.
System
(Individual,
Group/ organization)
Intervention Outcome
Client
(Individual, Family & Community)
4. Plan, Do, and Study, Act cycle:
It is an improvement model advocated by Dr. Deming which is still practiced widely
that contains a distinct improvement phase.
Use of PDSA model assumes that a problem has been identified and analyzed for its
most likely causes and that changes have been recommended for eliminating the likely
causes. Once the initial problem analysis is completed, a Plan is developed to test one of the
improvement changes. During the Do phase, the change is made, and data are collected to
evaluate the results. Study involves analysis of the data collected in the previous step. Data

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are evaluated for evidence that an improvement has been made. The Act step involves taking
actions that will ‗hardwire‘ the change so that the gains made by the improvement are
sustained over time.
5. Six Sigma:
It refers to six standard deviations from the mean and is generally used in quality
improvement to define the number of acceptable defects or errors produced by a process.
It consists of 5 steps: define, measure, analyze, improve and control (DMAIC).
 Define: Questions are asked about key customer requirements and key processes to
support those requirements.
 Measure: Key processes are identified and data are collected.
 Analyze: Data are converted to information; Causes of process variation are
identified.
 Improve: This stage generates solutions and make and measures process changes.
 Control: Processes that are performing in a predictable way at a desirable level are in
control.
6. Achieving Quality Care:
This shows a complex and interactive framework. It illustrates the idea of that
quality of care that is important to clients, practitioners, management and health
organizations, and to society as a whole. These groups may be interested in quality for
different reasons, will have different perspectives on quality and consequently have
different priorities. Their interests may be purely client-centered or influenced by
external pressures such as government policy, scarcity of resources or changing
technology.
 At an individual level, everyone affects quality of care-receptionists, telephones,
building maintenance staff, managers, clerical staff, caterers, and professional staff.
Quality is everyone‘s business. There is a potential problem here- since quality is
everyone‘s business it can become no one‘s business. In any organization someone
needs to take the responsibility for quality.

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Client Professional
Quality tools
 Chart audits
It is the most common method of collecting quality data using charts as quality
assessment tool.
 Failure mode and effect analysis: prospective view
It is a tool that takes leaders through evaluation of design weaknesses within
their process, enable them to prioritize weaknesses that might be more likely
to result in failure (errors) and, based on priorities decide where to focus on
process redesign aimed at improving patient safety.
 Root- cause analysis: retrospective view
It is sometimes called a fishbone diagram, used to retrospectively analyze
potential causes of a problem or sources of variation of a process. Possible
causes are generally grouped under 4 categories: people, materials, policies
and procedures, and equipment.
 Flow charts
These are diagrams that represent the steps in a process.
 Pareto diagrams
It is used to illustrate 80/ 20 rule, which states that 80% of all process variation
is produced by 20% of items.
 Histograms
It uses a graph rather than a table of numbers to illustrate the frequency of
different categories of errors.
 Run charts
These are graphical displays of data over time. The vertical axis depicts the
key quality characteristic, or process variable. The horizontal axis represents
time. Run charts should also contain a center line called median.
 Control charts
Other
Management
Qualitycare

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These are graphical representations of all work as processes, knowing that all
work exhibit variation; and recognizing, appropriately responding to, and
taking steps to reduce unnecessary variation.
Indicators of quality assurance
 Waiting time for different services in the hospital
 Medical errors in judgment, diagnosis, laboratory reporting, medical treatment or
surgical procedures, etc.
 Hospital infections including hospital- acquired infections, cross infections.
 Quality of services in key areas like blood bank, laboratories, X- ray department,
central sterilization services, pharmacy and nursing.
Quality improvement process- Steps
QI process steps include;
 Identify needs most important to the consumer of health care services.
 Assemble a multidisciplinary team to review the identified consumer needs and
services.
 Collect data to measure the current status of these services.
 Establish measurable outcomes and quality indicators.
 Select and implement a plan to meet the outcomes.
 Collect data to evaluate the implementation of the plan and achievement of outcomes.
Quality assurance cycle:
In practice, QA is a cyclical, iterative process that must be applied flexibly to meet the
needs of a specific program. The process may begin with a comprehensive effort to define
standards and norms as described in Steps 1-3, or it may start with small-scale quality
improvement activities (Steps 5-10). Alternatively, the process may begin with monitoring
(Step 4). The ten steps in the QA process are discussed.

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1. Planning for Quality Assurance
This first step prepares an organization to carry out QA activities. Planning begins
with a review of the organizations scope of care to determine which services should be
addressed.
2. Setting Standards and Specifications
To provide consistently high-quality services, an organization must translate its
programmatic goals and objectives into operational procedures. In its widest sense, a standard
is a statement of the quality that is expected. Under the broad rubric of standards there are
practice guidelines or clinical protocols, administrative procedures or standard operating
procedures, product specifications, and performance standards.
3. Communicating Guidelines and Standards
Once practice guidelines, standard operating procedures, and performance standards
have been defined, it is essential that staff members communicate and promote their use. This
will ensure that each health worker, supervisor, manager, and support person understands
what is expected of him or her. This is particularly important if ongoing training and
supervision have been weak or if guidelines and procedures have recently changed. Assessing
quality before communicating expectations can lead to erroneously blaming individuals for
poor performance when fault actually lies with systemic deficiencies.
4. Monitoring Quality
Monitoring is the routine collection and review of data that helps to assess whether
program norms are being followed or whether outcomes are improved. By monitoring key

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indicators, managers and supervisors can determine whether the services delivered follow the
prescribed practices and achieve the desired results.
5. Identifying Problems and Selecting Opportunities for Improvement
Program managers can identify quality improvement opportunities by monitoring and
evaluating activities. Other means include soliciting suggestions from health workers,
performing system process analyses, reviewing patient feedback or complaints, and
generating ideas through brainstorming or other group techniques. Once a health facility team
has identified several problems, it should set quality improvement priorities by choosing one
or two problem areas on which to focus. Selection criteria will vary from program to
program.
6. Defining the Problem
Having selected a problem, the team must define it operationally-as a gap between
actual performance and performance as prescribed by guidelines and standards. The problem
statement should identify the problem and how it manifests itself. It should clearly state
where the problem begins and ends, and how to recognize when the problem is solved.
7. Choosing a Team
Once a health facility staff has employed a participatory approach to selecting and
defining a problem, it should assign a small team to address the specific problem. The team
will analyze the problem, develop a quality improvement plan, and implement and evaluate
the quality improvement effort. The team should comprise those who are involved with,
contribute inputs or resources to, and/or benefit from the activity or activities in which the
problem occurs.
8. Analyzing and Studying the Problem to Identify the Root Cause
Achieving a meaningful and sustainable quality improvement effort depends on
understanding the problem and its root causes. Given the complexity of health service
delivery, clearly identifying root causes requires systematic, in-depth analysis. Analytical
tools such as system modeling, flow charting, and cause-and-effect diagrams can be used to
analyze a process or problem. Such studies can be based on clinical record reviews, health
center register data, staff or patient interviews, service delivery observations.
9. Developing Solutions and Actions for Quality Improvement
The problem-solving team should now be ready to develop and evaluate potential
solutions. Unless the procedure in question is the sole responsibility of an individual,
developing solutions should be a team effort. It may be necessary to involve personnel
responsible for processes related to the root cause.
10. Implementing and Evaluating Quality Improvement Efforts
The team must determine the necessary resources and time frame and decide who will
be responsible for implementation. It must also decide whether implementation should begin
with a pilot test in a limited area or should be launched on a larger scale. The team should
select indicators to evaluate whether the solution was implemented correctly and whether it
resolved the problem it was designed to address. In-depth monitoring should begin when the
quality improvement plan is implemented. It should continue until either the solution is

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proven effective and sustainable, or the solution is proven ineffective and is abandoned or
modified. When a solution is effective, the teams should continue limited monitoring.
JCAHO quality assurance guidelines/steps:
1. Assign responsibility:
According to the Joint Commission, ―The nurse administrator is ultimately
responsible for the implementation of a quality assurance program. Completing step one of
the Joint Commission‘s ten step process require writing a statement that described who is
responsible for making certain that QA activities are carried out in the facility. Assigning
responsibility should not be confused with assuming responsibility.
2. Delineate scope of care and services:
Scope of care refers to the range of services provided to patients by a unit or
department. To delineate the scope of care for a given department personnel should ask
themselves,‘ what is done in the department?‘
3. Identify important aspects of care and services:
Important aspects of nursing care can best be described as some of the fundamental
contribution made by nurses while caring for patients. They are the most significant or
essential categories of care practiced in a given setting. There is no prescribed list of
important aspects of care that every organization must monitor.
4. Identify indicators of outcome (no less than two; no more than four):
A clinical indicator is a quantitative measure that can be used as a guide to monitor
and evaluate the quality of important patient care and support service activities. Indicators are
currently considered as being of two general types i.e. sentinel events and rate-based.
Indicators also differ according to the type of event they usually measures (structure, process
or outcome).
5. Establish thresholds for evaluation:
Thresholds are accepted levels of compliance with any indicators being measured.
Thresholds for evaluation are the level of or point at which intensive evaluation is triggered.
A threshold can be viewed as a stimulus for action.
6. Collect data:
Once indicators have been identified, a method of collecting data about the indicators
must be selected. Among the many methods of data collection is interviewing patient/family,
distributing questionnaires, reviewing charts, making direct observation etc.
7. Evaluate data:
When data gathering is completed in the process of planning patients care, nurses
make assessments based on the findings. In the QA process as a whole, when data collection
has been completed and summarized, a group of nurses makes an assessment of the quality of
care.

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Practice
documentatio
n and data
management
orientation
Client
sa on
tisfacti
services
Case
conferences
Accreditation
and external
audit
Approaches
foe measuring
the quality of
nursing
practice
Shared
evaluation visits
and
observations
Record ,audit
,peer review
and utilization
review
Practice based
in-service
education
8. Take action:
Nurses are action-oriented professionals. For many nurses, the greater portion of
every day is spent on patient‘s intervention. These actions and interventions conducted by
nurses promote health and wellness for patients. Converting nursing energy into the QA
process requires formulating an action plan to address identified problems.
9. Assess actiontaken:
Continuous and sustained improvement in care requires constant surveillance by
nurses of the intervention initiated to improve care.
10. Communicate:
Written and verbal messages about the results of QA activities must be shared with
other disciplines throughout the facility.
APPROACHES FOR MEASURING THE QUALITY OF NURSING PRACTICE:
The VNA [visiting nurse association] measurement approaches are identified:
THE ESSENCE OF HEALTH CARE QUALITY ASSURANCE: -
The essential parameters of health care quality assurances are -
1) Concern for Excellence and Standards:-
All quality assurance initiatives whether implicit or explicit, focusing on individual
care or population services, undertaken by professionals, managers or consumers, must

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reflect an abiding interest in the provision of the highest possible quality care. If such
concern is not given primary quality assurance cannot take place, it should extend to all
aspects of care including the technical, the interpersonal and moral.
2) Specificity and explicitness:-
Despite the many difficulties health care quality assurance is, in aspiration at least, a
rational, explicit and practically based exercise. Standards are specified and
operationalised and measurement tools are developed for their appraisal. Respect for
their professional judgment and careful analysis of social and ethical dilemmas
provide essential context but the operation itself remains an attempt at developing
empirically rigorous procedures for the observation, analysis and review of care and
indeed , reflexively, for the observation, analysis and review of techniques for
appraising and improving quality.
3) Adaptation of a cyclical model:
All quality assurance systems involve appraisal of quality standards followed by
action for quality improvement. The American Nurses Association cycle of quality
assurance is an elaboration of the sequence. At each stage in the cycle the
observations and events of the previous stage influence the decisions to be made and
action to be undertaken in the next. If any one stage is missed or inadequately carried
out the others will suffer and the ultimate aim of quality maintenance or improvement
will not be achieved. The cycle is what is known as an ‗open‘ system that is one in
which direction is determined but actual destination may not be. This openness is
necessary to allow for the idea of continual quality improvement. Today‘s highest
possible standards may not satisfy the consumers and professionals of tomorrow.
4) Commitment:
Both individuals and organizations must be positively motivated to implement quality
assurance. Concern for quality and even compliance in the implementation of quality
assurance procedures are necessary but not sufficient. At the individual level time and
energy must be devoted to the exercise and persistence displayed in the face of
opposition. At the organizational level there must be recognition that quality
assurance does not just happen. it must be managed. That implies commitment of
time, energy and resources not just to the quality assurance system itself but to
designing and modifying it to match and complement the organizational climate in
which it operates.
Factors affecting quality assurance in nursing care:-
Quality assurance necessitates that institutions and health professionals render care in
a most efficient, effective and economical manner, there are some factors which are affecting
quality assurance in nursing care. They are as follows.
1. lack of Resources
2. personal problems
3. unreasonable patients and attendants
4. improper maintenance
5. absence of well informed populace

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6. absence of accreditation laws
7. legal redress
8. lack of incident review procedures
9. lack of good hospital information system
10. absence of conducting patient satisfaction surveys
11. lack of nursing care records
12. Miscellaneous factors like lack of good supervision, Absence of knowledge about
philosophy of nursing care, substandard education and training, lack of policy and
administrative manuals.
TOOLS OF THE CQI:
 Pareto Charts
 Fishbone Diagram
 Histograms
 Run Charts
 check sheets
 Flowchart
 Control Charts
Pareto Charts:
Tools define the source of variation in a process, allowing planning to decrease
inappropriate variation and improve quality. In order to validate the problems identified.
Examples of these ‗cause and effect‘ tools are the Pareto chart and analysis and the Fishbone
diagrams. The Pareto chart (see Chart#1) 30 and analysis is used when dealing with chronic
problems and helps one identify which of the many chronic problems to attack first. The
chronic problem with the highest number of events will show up on the Pareto chart with the
tallest bar, which represents the most frequent occurring problem. The idea behind Pareto
analysis is the 20/80 rule in that 20% of your errors / customers / input accounts for 80% of
your complications / income/ output.

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_ _
_ _
_ _
Goal problem
Procedures Materials
Pareto Chart, Continuous Process Improvement
Fishbone Diagram:
One analysis tool is the Cause-and-Effect or Fishbone diagram. These are also called
Ishikawa diagrams because Kaoru Ishikawa developed them in 1943. They are called
fishbone diagrams since they resemble one with the long spine and various connecting
branches.
Cause and effect chart:
The fishbone diagram organizes and displays the relationships between different causes for
the effect that is being examined. This chart helps organize the brainstorming process. The
major categories of causes are put on major branches connecting to the backbone, and various
sub-causes are attached to the branches.
Histogram:
This is a vertical bar chart which depicts the distribution of a data set at a single point in
time. A histogram facilitates the display of a large set of measurements presented in a table,
showing where the majority of values fall in a measurement scale and the amount of
variation. The histogram is used in the following situations:
1. To graphically represent a large data set by adding specification limits one can
compare;
2. To process results and readily determine if a current process was able to
produce positive results assist with decision-making
_
_
_
People
_
_
_
Equipment

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Run chart:
Most basic tool to show how a process performs over time. Data points are plotted in
temporal order on a line graph. Run charts are most effectively used to assess and achieve
process stability by graphically depicting signals of variation. A run chart can help to
determine whether or not a process is stable, consistent and predictable. Simple statistics
such as median and range may also be displayed.The run chart is most helpful in:
1. Understanding variation in process performance
2. Monitoring process performance over time to detect signals of change
3. Depicting how a process performed over time, including variation.
Allow the team to see changes in performance over time. The diagram can include a trend
line to identify possible changes in performance.
DATA COLLECTION:
Check sheets:
Check sheets are simply charts for gathering data. When check sheets are designed
clearly and cleanly, they assist in gathering accurate and pertinent data, and allow the data to
be easily read and used. The design should make use of input from those who will actually
be using the check sheets. This input can help make sure accurate data is collected and
invites positive involvement from those who will be recording the data.
Flowcharts :
A flow chart of the process is particularly helpful in obtaining an understanding of how the
process works. It provides a visual picture.
There are two types of flow charts that are particularly useful.
• Top Down Flow Chart and
• Deployment Matrix Flow Chart.
A Top Down Flow Chart shows only the essential steps in a process without detail. It focuses
on the steps that provide real value. It is particularly useful in helping the team to focus their
minds on those steps that must be performed in the final ‗improved‘ process.

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A Top Down Flow Chart is constructed as follows: -
by first listing the main steps across the top of the page and then listing the subsidiary steps
from the top down, below the main steps. The details are not recorded. For example, rework,
inspection, and typing are omitted.
The flow chart provides a picture of the process that the team can work on and simplify. It
allows people to focus on what should happen instead of what does happen.
Usually, most processes have evolved in an ad hoc manner. When problems occur, the
process is fixed. The end result is that a simple process has evolved into something complex.
A flow chart is a first step to simplification.
A Deployment Matrix Chart is another type of flow chart. This is useful because it shows
who is responsible for each activity, how they fit into the flow of work and how they relate to
others in accomplishing the overall job.
To construct a Deployment Matrix Flow Chart, the major steps in the process are:
• listed vertically down the left hand side of the page and the people or work groups are listed
across the top.
• The process is then charted to show who does what
CONTROL CHART:
A control chart is a statistical tool used to distinguish between variation in a process
resulting from common causes and variation resulting from special causes. It is noted that
there is variation in every process, some the result of causes not normally present in the
process (special cause variation). Common cause variation is variation that results simply
from the numerous, ever-present differences in the process. Control charts can help to

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maintain stability in a process by depicting when a process may be affected by special
causes. The consistency of a process is usually characterized by showing if data fall within
control limits based on plus or minus specific standard deviations from the center line.
Control charts are used to:
1. Monitor process variation over time
2. Help to differentiate between special and common cause variation
3. Assess the effectiveness of change on a process
4. Illustrate how a process performed during a specific period.
Using upper control limits (UCLs) and lower control limits (LCLs) that are statistically
computed, the team can identify statistically significant changes in performance. This
information can be used to identify opportunities to improve performance or measure the
effectiveness of a change in a process, procedure, or system.
CONTINUOUS QUALITY IMPROVEMENT TECHNIQUES:
Some of the continuous quality improvement techniques:
Improving quality by removing the causes of problems in the system inevitably leads
to improved productivity.
The person doing the job is most knowledgeable about that job.
This people want to be involved and do their jobs well.
Every person wants to feel like a valued contributor.
More can be accomplished working together to improve the system than having
individual contributors working around the system.
A structured problem solving process using graphical techniques produces better
solutions than in ',an unstructured process.
Graphical problem solving techniques will let you know where you are, where the
variations lie, the relative importance of problems to be solved .

21
BARRIERS OF CONTINUOUS QUALITY IMPROVEMENT:
Responsibility Barriers
Company‘s Directing Board  Because it‘s a general trend;
 Immediate results;
 Lack of a clear definition of the
organizational and the quality goals.
Operation Strategy  Lack of conformity between the
quality goals and the operation‘s
specificities
 Great amount of exceptions in order
to serve a determined number of
client
 Lack of actions that contribute to the
continuous improvement
Indicators  Lack of financial indicators;
 Don‘t represent the reality of the
operations.
Cost strategy  Lack of true analyzes concerning the

22
Table 3 - Barriers to the continuous improvement of quality in service operations
SOLUTIONS OF THE QUALITY IMPROVEMENT:
Some of the solutions of quality improvement are:
 Individual problem solving
 Rapid team problem solving
 Systematic team problem solving
 Process improvement solving
Individual Problem Solving
The simplest solution for quality improvement is the traditional focus on an individual
problem. If based on the discussions of your initial quality audit review you decide that you
have only one problem area to address, you can develop an individual problem solution. For
example, if your quality audit shows that you should concentrate on improving the safety
ranking of your line staff on one production line, you can work with those staff members to
develop improved safety protocols and implement a tracking system to document your
progress.
Rapid Team Problem Solving
If you have a more complex system to improve, you may want to try a rapid team
solution. In this model, you will implement small step-by-step changes and test those changes
as they are implemented. If the first step of your changes shows improvement in the quality
measures you are tracking, you will move on to the next step. Rapid team problem solving is
a less rigorous, more spontaneous approach to quality improvement and can be a good choice
for faster paced businesses.
Systematic Team Problem Solving
If your business needs indicate that you should undertake a more extensive quality
improvement goal, you may want to implement systemic team problem solutions. These
solutions require a more detailed analysis of the problem using sophisticated data collection
and evaluation. For example, if you want to concentrate on improving the level of customer
satisfaction with your product, you will want to do extensive surveys or focus groups of
current and potential customers. Based on this data, you can design solutions that address the
public perception of your entire business and improve your brand. But you will need to
cost of bad
 quality;
 Lack of analyzes of the financial gains
obtain with quality management
 Lack of a parameter for the
investment feedback.

23
constantly research and reassess your data to ensure that your systematic team solution is
effective.
Process Improvement Solving
Process improvement is the most complex of the quality improvement solutions. If
your business wants to make a full-time commitment to continuous quality improvement,
then process improvement is the solution for you. This solution involves setting up a
permanent quality improvement team to continually assess and amend your quality
interventions to ensure that improvement standards are met. Process monitoring solutions are
often used in health care or other settings where accreditation standards must be maintained.
CONCULSION:-
Quality assurance is the responsibility of the hospital management and (workers)
health personnel to assure a higher quality of care. The administrators generally have to face
the consequences in terms of poor reputation of the hospital, legal expenses and higher
hospital cost.
BIBLIOGRAPHY:
1. eHow.com http://www.ehow.com/about_5110198_basics-continuous-quality-
improvement.
2. BT Basavnthappa ―Nursing Administration‖ second edition Jaypee brothers
medical publishers 515-537
3. http://jama.ama-assn.org/content/266/13/1817.abstract
4. http://www.unboundmedicine.com/medline/

24
2. EVALUATION OF NURSING SERVICES
INTRODUCTION:
Evaluation is a judgemental process and as such, it reflects the beliefs, values and
attitudes of the participants of the programme. Evaluation is a decision making process that
leads to suggestions for actions to improve participant‘s effectiveness and programme
efficiency. Performance appraisal is a periodic formal evaluation of how the nurse has
performed her duties during a specific period.
DEFINITIONS:
1. Evaluation: Evaluation is an ongoing activity that begins at the first identification of
the need for an (educational) programme process throughout the planning and
implementing phases and extends well beyond the length of the programme itself.
2. Programme evaluation: Programme evaluation is a process of making informed
judgement about the character and the quality of a programme or parts thereof.
PURPOSES OF EVALUATION:
1. Clarify and define education/programme objectives.
2. Facilitate the improvement of curriculum and instruction of the programme.
3. Determine participant progress towards the achievement of the goals of the
programme.
4. Facilitate the maintenance of strength and elimination of weakness on the part of
participants.
5. Motivate the participants.
6. Provide sense of accomplishments (Psychological security) for the participants and
consumer.
7. Develop more reliable and valid instruments for measurement.
8. Determine the overall value (eg: cost efficiency) of undertakings for both participants
and consumer immediately over long period.
9. Establish and maintain standards to meet legal, profession and academic credentials.
TYPES OF EVALUATION:
1. Summative evaluation: Serves traditionally for rank ordering students and justifying
decisions regarding their passage to the following year or the obtaining degree.
Usually it occurs at the end of the programme, course or unit and is concerned with
whether the learner has mastered all designated behavioural objectives.
2. Formative evaluation: Occurs throughout the programme, course or unit, and
through feedback enables teacher and students or authority and worker to diagnose
learning needs or any specific needs to provide appropriate remedial strategies and
pace the student or worker learning or equip according to needs and abilities.

25
Describing
Monitoring
Recommending
MODEL OF THE EVALUATION PROCESS
Programme Observing Information
actions Measuring
Relevance
Relatedness
Analysing Accountability
Development Validity of goods
worth of actions
Synthesizing support & constraints
Evaluation
Explanation of the model:
There are many ways to consider nursing programme. Nursing programme consists
number of related parts, i.e. curriculum, teaching of nursing, practice of nursing and research
and administration, functioning together to achieve common goals or purposes. The values
that reflect the development of a programme are throughout to be:
i) The relevance of the goals, activities, and outcomes of the programme to the particular
client or community.
ii) The relatedness of the different parts of the programmes in seeking common goals and in
discovering means to achieve them; and
iii) The accountability of the programme in assuming responsibility for its goals, methods
and outcomes.
Thus, relevance, relatedness and accountability are viewed as the critical attributes or
criteria of programme development. When these criteria applied in the nursing practice, assist
in describing the development of that programme or performance of the nursing procedures
or carrying out nursing measures for client and form the basis of the evaluations process. The
model outlines the process of evaluation.

26
First the evaluator observes measures and describes the programme goals and actions
and in general collects information to provide a database for analysis. The criteria provide the
structure for the analysis and the results, conclusions or inference indicate the development of
the programme.
The state development provides the information base for monitoring the programme so
that the direction of goals and activities may be changed, and the accumulated information
provides a jeed forward into the programme plans or nursing care plans. This process
describes the everyday monitoring and shaping of the nursing programme by the person
involved. Next the information of developments is scrutinized and synthesized in relation to
the questions that the evaluation seeks to answer. This phase usually leads to a series of
recommendations for the purpose of directing the future development of the nursing care
programme.
PROCESS OF EVALUATION:
 The first step in the evaluation process is goal setting. The values and beliefs of the
agency, the providers and the clients provide the basis for goal setting and should be
considered at every step of the evaluation process. Childhood diseases would lead to a
programme goal to decrease the incidence of early childhood diseases in the place
where the programme is planned.
 The second step is determining goal measurement. In the case of the previous goal,
disease incidence would be an appropriate goal measurement.
 The third step is identifying goal-attaining activities. This would include such
activities as media presentations urging parents to have their children immunized.
 The fourth step is making the activities operational, i.e. actually administering the
immunizations.
EVALUATE
PROGRAMME
GOALS
MEASURE
GOAL
EFFECT MAKE ACTIVITIES
OPERATIONAL
SETGOALS
DETERMINE
GOAL
MEASUREMENT
IDENTIFY
GOAL
ATTAINING
ACTIVITIES

27
 The fifth step is measuring the goal effect, which consists of reviewing the records
and summarizing the incidence of early childhood disease before and after the
programme.
 The final step is evaluation of the programme, determining whether the programme
goal was achieved.
PRINCIPLES OF PERFORMANCE EVALUATION
1. Assess performance in relation to behaviourally stated work goals:
Evaluation of the employee should be based on behaviourally stated performance standards
for the position occupies, e.g. a nurse‘s job performance should be evaluated with reference
to progress towards those goals.
2. Observe a representative sample of employees total work activities.
An adequate, representative sample of the nurse‘s job behaviour should be observed to
provide a basis for evaluation. Care should be taken to be evaluated nurse‘s usual or
consistent job behaviour and to avoid undue attention to a single, typical instance of superior
or incept behaviour.
3. Compare supervisors evaluation with employees self evaluation:
The nurse should be given a copy of her or his job description, performance standards,
and performance evaluation form to review before the evaluation conference, so that the
nurse and supervisor can approach their discussion from the same frame of reference.
4. Cite specific examples of satisfier and unsatisfactory performance:
While documenting nurse‘s performance, the supervisor should indicate areas of
performance that are satisfactory and the areas that need improvement or that are
unsatisfactory with evidence.
5. Indicate which job areas have highest priority for improvement:
When served areas of performance need improvement, the supervisor should specify
which areas are to be given highest priority.
6. Evaluation conference should be held in good atmosphere:
For which the evaluation conference should be scheduled at a time convenient for nurse
and supervisor, and should be held in pleasant surroundings, and should allow adequate
time for discussion.
7. The purpose of evaluation is to improve work performance and job satisfaction:
The goal of evaluation process should be improve employee performance and
satisfaction, rather than to threaten or punish the employee for performance inadequacy.
An employee can withstand strong criticism from supervisor who is considerate of the
employee‘s feelings and offers to coach her/him towards improved performance.

28
EVALUATING A GROUP:
Group evaluation includes two important areas, process measurement and outcomes
measurement. The first examines ongoing group interaction, and the second looks at the
group‘s final product.
1. Process evaluation:
Process evaluation is an assessment of how well a group or project is functioning.
Process evaluation can be done in several ways. One useful method is to have an outside
observer sit in on the group, watch for specific behaviours, and then give reactions to the
group. The observer can use one of several guides available for this purpose. Another method
is to have a group member act as an impartial observer during a session in which the member
only observes and retrains from participating. The group itself may diagnose its health by
periodically or even regularly using some form of checklist or questionnaire, followed by
discussion. In general, a group needs to examine all of the roles listed earlier and ask
questions pertaining to areas such as communication skills and patterns, responses to
leadership style, group climate, stage of group development, and progress on group
objectives.
2. Outcome evaluation:
Outcome evaluation is a measurement of the end results or consequences of a programme
or intervention. Clear goals and specific objectives should be stated. Goals are broad
statements of the overall purpose of the group. Objectives are statements measurable
behaviours that describe specific steps toward accomplishment of goals. For example, the
group‘s goal may be to learn the techniques of natural childbirth. Objectives should describe
separate behaviours, such as demonstrating specific breathing techniques or exercises. Thus
objectives that describe outcome behaviours become criteria for measuring the group‘s
performance.
PROGRAMME EVALUATION:
Evaluation is the process of collecting data, presenting them in a convenient form and
using them to form judgements to reach a decision about an activity on other type of process.
A community health service is a process, which starts with planning and ends with evaluation
of that programme.
Purpose of evaluation of community health programme:
1. The modification of the programme to be at par with the problem arising in the
community or with the felt need of the community.
2. Ensuring objectives for the continuing education of the staff members for their
development.
3. Serving as a basis for diagnosis of professional problems and potentialities.
4. Forming a basis for future plan of the programme.
5. Helping in research studies for innovation in community health nursing service.
6. Providing a review of the standards of work for both the supervisor and staff.

29
4. DEVELOPMENT OF STANDARDS
INTRODUCTION
Standard is an acknowledged measure of comparison for quantitative or qualitative
value, criterion, or norm. A standard is a practice that enjoys general recognition and
conformity among professionals or an authoritative statement by which the quality of
practice, service or education can be judged. It is also defined as a performance model that
results from integrating criteria with norms and is used to judge quality of nursing objectives,
orders and methods
A standard is a means of determining what something should be. In the case of
nursing practice standards are the established criteria for the practice of nursing. Standards
are statements that are widely recognised as describing nursing practice and are seem as
having permanent value.
NURSING STANDARDS
A nursing care standard is a descriptive statement of desired quality against
which to evaluate nursing care. It is guideline. A guideline is a recommended path to safe
conduct, an aid to professional performance.A nursing standard can be a target or a gauge.
When used as a target, a standard is a planning tool. When used as a gauge against which to
evaluate performance a standard is a control device.
A standard is a statement of quality. It is definite level of excellence or adequately
required, aimed at or possible. Standard is an acknowledged measure of comparison for
qualitative, or qualitative, or qualitative value, criterion, and norm.
DEFINITION
A nursing care standard is a descriptive statement of desired quality against which to evaluate
nursing care. Characteristics of Standard
Characteristics of Standard
 Standards statement must be broad enough to apply to a wide variety of settings.
 Standards must be realistic, acceptable, attainable.
 Standards of nursing care must be developed by members of the nursing profession;
preferable
 nurses practising at the direct care level with consultation of experts in the domain.
 Standards should be phrased in positive terms and indicate acceptable performance
good, excellence etc.
 Standardsof nursing care must express what is desirable optional level.
 Standards must be understandable and stated in unambiguous terms.
 Standards must be based on current knowledge and scientific practice.
 Standards must be reviewed and revised periodically.
 Standards may be directed towards an ideal ,ie,optional standards or may only specify
the minimal care that must be attained,ie, minimum standard.

30
 And one must remember that standards that work are objective, acceptable,
achievable and flexible.
Purposes of Standards
 Setting standard is the first step in structuring evaluation system. The following are
some of the purposes of standards.
 Standards give direction and provide guidelines for performance of nursing staff.
 Standards provide a baseline for evaluating quality of nursing care
 Standards help improve quality of nursing care, increase effectiveness of care and
improve efficiency.
 Standards may help to improve documentation of nursing care provided.
 Standards may help to determine the degree to which standards of nursing care
maintained and take necessary corrective action in time.
 Standards help supervisors to guide nursing staff to improve performance.
 Standards may help to improve basis for decision-making and devise alternative
system for delivering nursing care.
 Standards may help justify demands for resources association.
 Standards my help clarify nurses area of accountability.
 Standards may help nursing to define clearly different levels of care.
Major objectives of publishing, circulating and enforcing nursing care standards are to:
1. improve the quality of nursing care,
2. decrease the cost of nursing, and
3. determine the nursing negligence.
Sources of Nursing Care Standards
It is generally accepted that standards should be based on agreed up achievable level of
performance considered proper and adequate for specific purposes. The standards can be
established, developed, reviewed or enforced by variety of sources as follows:
 Professional organisation, e.g. Associations, TNAI,
 Licensing bodies, e.g. Statutory bodies, INC,
 Institutions/health care agencies, e.g. University Hospitals, Health Centres.
 Department of institutions, e.g. Department of Nursing.
 Patient care units, e.g. specific patients' unit.
 Government units at National, State and Local Government units.
 Individual e.g. personal standards

31
Classification of Standards
There are different types of standards used to direct and control nursing actions.
1. Normative and Empirical Standards
Standards can be normative or empirical. Normative standards describe practices
considered 'good' or 'ideal' by some authoritative group. Empirical standards describe
practices actually observed in a large number of patient care settings. Here the normative
standards describe a higher quality of performance than empirical standards. Generally
professional organisations (ANA/TNAI) promulgate normative standards where as low
enforcement and regulatory bodies (INC/MCI) promulgate empirical standards.
2. Ends and Means Standards
Nursing care standards can be divided into ends and means standards. The ends
standards are patient-oriented; they describe the change as desired in a patient's physical
status or behaviour. The means standards are nursing oriented, they describe the activities and
behaviour designed to achieve the ends standards. Ends (or patient outcome) standards
require information about the patients. A means standard calls for information about the
nurses performance.
3. Structure,Process and Outcome Standards
Standards can be classified and formulated according to frames of references (used for
setting and evaluating nursing care services) relating to nursing structure, process and
outcome, because standard is a descriptive statement of desired level of performance against
which to evaluate the quality of service structure, process or outcomes.
a. Structure Standard
A structural standard involves the 'set-up' of the institution. The philosophy, goals and
objectives, structure of the organisation, facilities and equipment, and qualifications of
employees are some of the components of the structure of the organisation, e.g.
recommended relationship between the nursing department and other departments in a health
agency are structural standards, because they refer to the organisational structure in which
nursing is implemented. It includes people money, equipment, staff and the evaluation of
structure is designed to find out the effectiveness ,degree to which goals are achieved and
efficiency in terms of the amount of effort needed to achieve the goal.
The structure is related to the framework, that is care providing system and resources
that support for actual provision of care. Evaluation of care concerns nursing staff, setting
and the care environment. The use of standards based on structure implies that if the structure
is adequate, reliable and desirable, standard will be met or quality care will be given.

32
b. Process Standard
Process standards describe the behaviors of the nurse at the desired level of
performance The criteria that specify desired method for specific nursing intervention are
process standards. A process standard involves the activities concerned with delivering
patient care.These standards measure nursing actions or lack of actions involving patient
care.The standards are stated in action-verbs, that is in observable and measurable terms.eg
:the nurse assesses", "the patient demonstrates". The focus is on what was planned, what was
done and what was communicated or recorded. Therefore, the process standards assist in
measuring the degree of skill, with which technique or procedure was carried out, the degree
of client participation or the nature of interaction between nurse and client.In process
standard there is an element of professional judgement determining the quality or the degree
of skill. It includes nursing care techniques, procedures, regimens and processes.
c. Outcome Standards
Descriptive statements of desired patient care results are outcome standards because
patient's results are outcomes of nursing interventions. Here outcome as a frame of reference
for setting of standards refers to description of the results of nursing activity in terms of the
change that occurs in the patient. An outcome standard measures change in the patient health
status. This change may be due to nursing care, medical care or as a result of variety of
services offered to the patient. Outcome standards reflect the effectiveness and results rather
than the process of giving care.
LEGAL SIGNIFICANCE OF STANDARDS
Standards of care are guidelines by which nurses should practice.If nurses do not
perform duties within accepted standards of care,they may place themselves in jeopardy of
legal action.Malpractice suit against nurses are based on the charge that the patient was
injured as a consequence of the nurses failure to meet the appropriate standards of care.
To recover losses from a charge of malpractice, a patient must prove that:
1. A patient-nurse relationship existed such that the nurse owed to the patient a duty of
due care,
2. The nurse deviated from the appropriate standard of care,
3. The patient suffered damages,
4. The patient's damages resulted from the nurses deviations from the standard of care.
CONCLUSION
Quality assurance is to provide a higher quality of care. It is necessary that nurses
develop standards of patient care and appropriate evaluation tools, so that professional
aspects of nursing involving intellectual and interpersonal activities. Quality will be ensured
and attention will be given to the individual needs and responses to patients.The formulation
of standards is the first step towards evaluating the nursing care delivery. The. standards

33
serve as a base by which the quality of care can be judged. This judgement may be according
to a rating or other data that reflect the conformity of existing practice with the established
standards. The standards must be written, regularly reviewed and well-known by the nursing
staff.
REFERENCES
1. Basavanthappa BT. Nursing Administration. 1st edn. New Delhi: Jaypee Brothers;
2000
2. Johnson M and Closkey J.C. The Delivery Of Quality Health Care Series On Nursing
Administration. London: Mosby 1992
3. Koch M.W And Fairly T.M. Integrated Quality Management: The Key To Improving
Nursing Care Quality. st Edition.St.Louis,Missouri:MosbyPublications;1993.
4. Ward MJ, Price SA .Issues in nursing administration. St.Louis: Mosby;1991.
5. Marquis B.L. ,Hutson C.J . Leadership roles and management functions in nursing–
Theory and application. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2006.
6. Douglass L M. The effective nurse- leader and manager. 5th ed. Mosby: St. Louis;
1996.
7. Morrison M. Professional skills for leadership. Mosby: US; 1993.
8. Ellis J R, Hartley C L. Managing and Co-ordinating nursing care. 3rd ed. Lippincott:
Philadelphia;1995.
9. Anthony, Mary K., Theresa; Hertz, Judith .Factors Influencing Outcomes After
Delegation to Unlicensed Assistive Personnel. JONA. 30(10):474-481, October
2000.
10. Cheryl L. Plasters, Seagull F J, Xiao Y. Coordination challenges in operating-room
management: an in-depth field study. Amia annu symp proc; 2003.

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5. STRUCTURE STANDARD
INTRODUCTION
Hospitals are the most complex of building types. Each hospital is comprised of a
wide range of services and functional units. These include diagnostic and treatment functions,
such as clinical laboratories, imaging, emergency rooms, and surgery; hospitality functions,
such as food service and housekeeping; and the fundamental inpatient care or bed-related
function. This diversity is reflected in the breadth and specificity of regulations, codes, and
oversight that govern hospital construction and operations. Each of the wide-ranging and
constantly evolving functions of a hospital, including highly complicated mechanical,
electrical, and telecommunications systems, requires specialized knowledge and expertise.
DEFINITION OF STRUCTURE
According to Van Maanen (1984: 18),‖ structure is the evaluation of the organization
of the institution delivering care; the conditions under which care is provided and its impact
on quality‖, i.e. buildings, budget and equipment.
CONCEPT OF STRUCTURE STANDARD IN QA
 It involves the setup of the institution.
 The philosophy, goals and objectives, structure of the organization, facilities and
equipment and qualifications of the employees.
 It is recommended relationships between the nursing department and other department
in a health agency are structural standards because they refer to the organizational
structure in which nursing implemented.
 It includes people money, equipment, staffing policies etc.
 The structure is related to the framework, that is care providing system and resources
that support for actual provisions of care.
 The use of standards based on structure is adequate, reliable and desirable, standard
will be met or quality care will be given
NURSING ORGANISATIONAL STRUCTURE
 The primary purpose of establishing nursing service is to provide efficient and
effective nursing care services as an integral hospital resource for the achievement of
total delivery of comprehensive health programs offered by the hospital.
 For which the departments and units of the nursing units are organized as a sub
system of patient care system in such a manner that nursing personnel can collectively
work to achieve excellence in nursing care services and assist in meeting the
objectives of the entire hospital system.
 Nursing is a vital aspect of health care and needs to be properly organized. A nurse is
in frequent contact with the patients and hence her or his role in restoring, health and
confidence of the patients is almost importance of the quality of nursing care and the
management of nursing staff, which will reflect the image of the hospital.

35
Nursing organizational structure should meet
 Permit the nursing staff of meet physical, socioeconomical, and spiritual needs of the
client.
 Permit adaptiveness to a given situation at a given point of time.
 permit decision making at the level the action takes place
 Permit And Develop Proper Communication System.
 Exact accountability for the job at each level of the organization.
 Allow to develop nursing service policies in the context of general policies of the
hospital.
 Foster the team approach to client care.
 Allow for grouping of patients by level of care and or specialty service.
 Allow highest possible quality of nursing care.
 Develop programs of nursing education.
 Promote nursing research studies.
 Promote participation in the allied health organizations and supportive health
activities.
 Participate the nurse in budget preparation of hospital service.
STAGES OF THE DEVELOPMENT OF INTERNATIONAL STANDARDS
ACCORDING TO NATIONAL INSTITUTE OF BUILDING SCIENCES,-(Hospital)
DEFINITION
"A functional design can promote skill, economy, conveniences, and comforts; a non-
functional design can impede activities of all types, detract from quality of care, and raise
costs to intolerable levels."
Hardy and Lammers
THE BASIC FORM OF A HOSPITAL IS, IDEALLY, BASED ON ITS FUNCTIONS
 Bed-related inpatient functions
 Outpatient-related functions
 Diagnostic and treatment functions
 Administrative functions

36
 Service functions (food, supply)
 Research and teaching functions
CODES AND STANDARDS
 FGI Guidelines for Design and Construction of Hospitals and Health Care
Facilities,
 State and local building codes are based on the model International Building Code
(IBC).
 NFPA 101 (Life Safety Code), NFPA 70 (National Electric Code), and Architectural
Barriers Act Accessibility Guidelines (ABAAG) or Uniform Federal Accessibility
Standards (UFAS).
 The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).
 The American with Disabilities Act (ADA) applies to all public facilities and greatly
the building design with its general and specific accessibility requirements.
 The Architectural Barriers Act Accessibility Guidelines (ABAAG) or the Uniform
Federal Accessibility Standards (UFAS) apply to federal and federally funded
facilities. The technical requirements do not differ greatly from the ADA
requirements.
 Regulations of the Occupational Safety and Health Administration (OSHA) the design
of hospitals, particularly in laboratory areas.
GENERAL STANDARDS OF CONSTRUCTION AND EQUIPMENT FOR
HOSPITALS:
The site of the hospital must be away from nuisances that may be detrimental to the
proposed services, such as commercial or industrial. Developments or other types of facilities
that produce noise or air pollution. A site plan must be submitted to the department.
Physical relationships between these functions determine the configuration of the
hospital. Certain relationships between the various functions are required—as in the
following flow diagrams.

37
These flow diagrams show the movement and communication of people, materials,
and waste. Thus the physical configuration of a hospital and its transportation and logistics
systems are inextricably intertwined in a large hospital, the form of the typical nursing unit,
since it may be repeated many times, is a principal element of the overall configuration.
Nursing units today tend to be more compact shapes than the elongated rectangles of the past.
Compact rectangles, modified triangles, or even circles have been used in an attempt to
shorten the distance between the nurse station and the patient's bed.
JACHO STRUCTURE STANDARD
JOINT COMMISSION INTERNATIONAL
The Joint Commission International (JCI) was established in 1997 by JCAHO with the
objective of ―helping to improve the quality of patient care by assisting international
healthcare organisations, public health agencies, health ministries, and others evaluate,
improve, and demonstrate the quality of patient care and enhance patient safety.
AN EFFICIENT HOSPITAL LAYOUT SHOULD
 Promote staff efficiency by minimizing distance of necessary travel between
frequently used spaces.

38
 Allow easy visual supervision of patients by limited staff.
 Include all needed spaces, but no redundant ones. This requires careful pre-design
programming.
 Provide an efficient logistics system, which might include elevators, pneumatic tubes,
box conveyors, manual or automated carts, and gravity or pneumatic chutes, for the
efficient handling of food and clean supplies and the removal of waste, recyclables,
and soiled material
 Make efficient use of space by locating support spaces so that they may be shared by
adjacent functional areas, and by making prudent use of multi-purpose spaces
 Consolidate outpatient functions for more efficient operation—on first floor, if
possible—for direct access by outpatients
 Group or combine functional areas with similar system requirements
 Provide optimal functional adjacencies, such as locating the surgical intensive care
unit adjacent to the operating suite.
FLEXIBILITY AND EXPANDABILITY
Since medical needs and modes of treatment will continue to change, hospitals
should:
 Follow modular concepts of space planning and layout.
 Use generic room sizes and plans as much as possible, rather than highly specific ones
 Be served by modular, easily accessed, and easily modified mechanical and electrical
systems
THERAPEUTIC ENVIRONMENT
 Hospital patients are often fearful and confused and these feelings may impede
recovery.
 Every effort should be made to make the hospital stay as unthreatening, comfortable,
and stress-free as possible.
 A hospital's interior design should be based on a comprehensive understanding of the
facility's mission and its patient profile.
 The characteristics of the patient profile will determine the degree to which the
interior design should address aging, loss of visual acuity, other physical and mental
disabilities, and abusiveness

39
PROTRUDING OBJECTS
GENERAL
Objects projecting from walls (for example, telephones) with their leading edges
between 27 in and 80 in (685 mm and 2030 mm) above the finished floor shall protrude no
more than 4 in (100 mm) into walks, halls, corridors, passageways, or aisles Objects mounted
with their leading edges at or below 27 in (685 mm) above the finished floor may protrude
any amount Free-standing objects mounted on posts or pylons may overhang 12 in (305 mm)
maximum from 27 in to 80 in (685 mm to 2030 mm) above the ground or finished floor
Protruding objects shall not reduce the clear width of an accessible route or maneuvering
space .
EACH FLOOR,
Parking and visitor Loading Zone, Drinking Fountains and Water Coolers Storage
,Alarms,Telephones, Seating, Tables, and Work Surfaces,, Assembly Areas.
OTHERS:
Stairs,Elevators, Doors.
HANDRAILS HAVE THE FOLLOWING FEATURES:
 Handrails shall be provided along both sides of ramp segments.
 The inside handrail on switchback or dogleg ramps shall always be continuous.
 If handrails are not continuous, they shall extend at least 12 in (305 mm) beyond the
top and bottom of the ramp segment and shall be parallel with the floor or ground
surface.
 The clear space between the handrail and the wall shall be 1-1/2 in (38 mm).
 Gripping surfaces shall be continuous.
 Top of handrail gripping surfaces shall be mounted between 30 in and 34 in (760 mm
and 865 mm) above ramp surfaces.
 Ends of handrails shall be either rounded or returned smoothly to floor, wall or post.
 Handrails shall not rotate within their fittings.
CLEANLINESS AND SANITATION:
 Hospitals must be easy to clean and maintain. This is facilitated by:
 Appropriate, durable finishes for each functional space
 Careful detailing of such features as doorframes, casework, and finish transitions to
avoid dirt-catching and hard-to-clean crevices and joints

40
 Adequate and appropriately located housekeeping spaces.
 Special materials, finishes, and details for spaces which are to be kept sterile, such as
integral cove base. The new antimicrobial surfaces might be considered for
appropriate locations.
ALL AREAS, BOTH INSIDE AND OUT, SHOULD:
 Comply with the minimum requirements of the Americans with Disability Act (ADA)
and, if federally funded or owned, the Uniform Federal Accessibility Standards
(UFAS)
 In addition to meeting minimum requirements of ADA and/or UFAS, be designed so
as to be easy to use by the many patients with temporary or permanent handicaps
 Ensuring grades are flat enough to allow easy movement and sidewalks and corridors
are wide enough for two wheelchairs to pass easily
 Ensuring entrance areas are designed to accommodate patients with slower adaptation
rates to dark and light; marking glass walls and doors to make their presence obvious
CONTROLLED CIRCULATION:
 A hospital is a complex system of interrelated functions requiring constant movement
of people and goods. Much of this circulation should be controlled.
 Outpatients visiting diagnostic and treatment areas should not travel through inpatient
functional areas nor encounter severely ill inpatients
 Typical outpatient routes should be simple and clearly defined
 Visitors should have a simple and direct route to each patient nursing unit without
penetrating other functional areas
 Separate patients and visitors from industrial/logistical areas or floors
 Outflow of trash, recyclables, and soiled materials should be separated from
movement of food and clean supplies, and both should be separated from routes of
patients and visitors
 Transfer of cadavers to and from the morgue should be out of the sight of patients and
visitors
AESTHETICS:
 Aesthetics is closely related to creating a therapeutic environment (homelike,
attractive.) It is important in enhancing the hospital's public image and is thus an
important marketing tool. A better environment also contributes to better staff morale
and patient care. Aesthetic considerations include:
 Increased use of natural light, natural materials, and textures

41
 Use of artwork
 Attention to proportions, color, scale, and detail
 Bright, open, generously-scaled public spaces
THE OUT PATIENT DEPARTMENT:
 The outpatient department should function along with other departments in all
consideration of the hospital organization –policy, facilities, financing, patient care,
teaching and research.
 The function of the OPD should reflect the other activities of all other departments.
 The OPD should be located close to main entrance particularly where the public
transportation is provided.
 The department should be adjacent to the casualty, emergency and admitting unit.
 The OPD there should be a reception and enquiry both should be connected with
effective communication.
 Depends the type of hospital the OPD should have eye,ear,nose ,throat, dental
,medical .surgical ,obstetric and gynae,paediatric and mental health clinics etc.
 In OPD should have a laboratory and other diagnostic facilities and also there should
be a pharmacy for distribution of drugs to the outpatients.
 The outpatient department should provide an environment which will acquaint the
patient with matter of health and hygienic practices for that the suitable posters should
be displayed on the respective units of the departments.
 The provision has to be made for dealing properly and efficiently with medical and
surgical emergencies from whatever case.
 Every hospital the causuality should provide the provision for single fractures, cuts
needing suturing, abscess conditions, poisoning,tetanus and other conditions.
 The casuality department should provide round the clock services.
 A hospital expecting 500 outpatient perday over 300 normal working days in a year
require 7500 square feer of space.
 8 square feet feet per patient is required in waiting area.reception and enquiry area
should face the patient.
 To avoid noise level in the reception area(150 db) an acoustic ceiling is desirable.
 The OPD should be easy to clean and well ventilated.
 The waiting and enquiry lobby should have display boards.

42
 Wheel chair and stretcher trolley parking area should be provided very close to the
entrance.
 Each clinic should be equipped and artificial lighting should be provided.
 The outpatient record room should be located at the end of the main waiting hall.
 The dispensary area required is minimum 250 square feet. There should be facilities
for storage ,getting raw materials, preparation and dispensing.
 Adequate waiting space adjoining to the dispensing counters should be given.
 A minor operating theatre should be provided with the facilities of 20 m2.
NURSING UNIT FACILITIES SPACE REQUIREMENTS
 Nursing director‘s office.
 Asst directors and supervisor office
 Reception control area
 Secretarial and clerical area
 Conference room
 Storage –personnel files, administrative files, and office supplies.
 The nurses‘ room can be divided as intensive care, intermediate care, self care and
long term care.
 The ward accommodation should be classified as four groups as primary, auxillary,
sanitary and ancillary.
 The size of the nursing unit depends upon the number of patients admitted.
 The bed room should be 5 m wide and 6 m long. central corridors have to be
minimum of 2.5 0 m wide and ancillary area should have the floor area of 15 m2per
bed as 25 bedded ward.
 25 bedded as 15 m2 per bed is require 384 m2.
 The shape of the nursing unit can be as t shaped or E, H, box plan or cross plan.
 The minimum floor space for a multiple bed room 4 bedded is 7.0 m2 and single bed
room is 14.00m2 and 2 bed room is 21.oom2.
 Ceiling height of the ward unit should be in-between 3 and 3.60 m.and the width of
the corridors should be 2.40 m to facilitate the movement of the trolley .the windows
openings for admitting light is as 20 percent of floor area.

43
 The doors of all patients should be at 2.0 m .a standard hospital bed should be as 1.0
m in breath and 2.15m in length .the doors must not open towards the corridor.
Ventilation grill on the top of the door shutters should be provided.
 Bed side lockers and built in cupboard should be provided.
 The nurses‘ station should be open to the corridor but it should be separated. The
room should be built in cupboards for storage of drugs ,dressings and instruments
.closet for narcotics and dangerous drugs and refrigerator for for storage of antibiotics
and sensitive inject able should be provided.
 Sanitary facilities such as bathrooms, wash basins, dirty utility room should be
provided. The wash basin should have the 91.5 cm at the basin rim.and wheel chair
patients at the height of 70 cm deep with a narrow apron.
 The nurses unit also has treatment and dressing rooms, isolation room, ward pantry,
clean utility room and day room.
INTENSIVE CARE UNIT
 The ICU bed or cubicle require space to accommodate ventilator,cardiac
monitors,pulse oximeter,suction machine ,oxygen machine ,procedure trolley and
mobile x ray machine.each patient bed area should have a minimum floor area of 150-
200 square feet and each bed is separated by adjacent bed by a closed bay design.
 The work zone on both side of the bed requires a width of 19 feet .there should be a
minimum distance of 8 feet between each beds.
 Each bed should have a oxygen outlet and central suction outlet and a number of
power outlets.
 The circulation area should not be less than 20 percent of floor area.
 The central nursing station should be located to view all the patients at a time.
 Bed should be located such a way that the patient can see the nurse directly than other
patient.
 Portable x ray,us,equipment for respiratory theraphy should not be clutter in patient
area but should be located nearby equipment room.
 A storage room for equipment ,ECG machine,and numerous other items.
 The ICU should be centrally air conditioned.7-8 air changes per hr and a positive
pressure to prevent re entry of outside contaminated air.
 Each patient bed should have multible electrical gadgets and 4-5 power sockets can
be provided.
 The main light at the bed head should be fitted with a dimmer light.and the spot
focusing light can be used.

44
 A reliable alternate source of power is must in ICU.the entire ICU can be connected
by a stabdby generator.
 For relative and friends a visitors lounge with barriers should be provider .
Policies-type of pts admitted,refusal of admission,admission procedure,
THE OPERATION THEATRE SHOULD HAVE THE FOLLOWING FACILITIES
 The operating room should consist of OT tables.
 A lay- up room which connects directly with operating room is used to prepare trolly
with all the equipment needful for an operation.
 Wash-up room opening immediately off the operating room contains the sinks and the
disposal lifts. All used dirty material goes in this room.
 Anesthesia room:which is also open directly into the operating room is equipped
permanently for the use of anesthetist.
 scrubbing up room: in which the surgeons and nurses scrub up and put on sterilized
gloves ,mask and gown
 In addition OT should be equipped with necessary supplies and equipments which
include linen, surgical instruments, OT tables, Boyer apparatus, O2, N2 and other
gases.
 Recovery room should be attached to operation theatre for the reception of the patient
after the surgery.
 Operation room should have the square feet for major 360 square feet and minor 324
s.feet.scrub room and sterllisation 80 s. feet.orthropedic theatre 240 s.feet.and
reception and preparation room 160 s.feet.sterile storage 160 s.feet.equipment storage
160 s.feet.anesthetist room 160 s.feet.anesthetist store 80 s.feet .doctors locker,change
room rest room and toilet 120 s.feet.nurses 120 s.feet.
 General linen storage 120 s.f.recovery room 480 s.feeet.mobile x ray and dark room
120 s,f,trolley bay 80 s,f.safaimans alcove 80 s f. waiting room toilet 160 s
feet.reception 100 s f.gowned waiting booth 80 s f.mens change locker 120 s feet and
female change locker 120 s feet.
MATERNITY AND OBG UNIT
 The maternity ward should be attractive, comfortable and restful.
 The antenatal clinic should be situated where practicable on part of the ground floor
off or adjoining the maternity wing.
 The size of the clinic will be governed to some extent by the number of times the
obstetrician will see the an expectant mother before delivery.

45
 in patient facility of maternity department should include admitting room, labor and
delivery room ,equipment for anesthesia, recovery room ,postpartum wards etc.
PAEDIATRIC UNIT:
 The outpatient services for children are important part of the pediatric services.
 In pediatric clinics, more space, have to be kept open to enable the clinic to accept a
patient without appointment who present themselves with urgent conditions.
 Children‘s are should be grouped by age than diagnosis.
 In designing the pediatric unit a large proportion of isolation room and facilities for
mothers to come in to the hospital with their children.
 There is also a large play room and a school room should be provided.
 And also there should be a unit for premature infant.
 Here a separate glass walled cubicle is desirable for each infant.
 Each cubicle should be equipped with devices for controlling temperature and
humidity and each should be connected to a oxygen supply.
 Premature infants are always prone to get infection, so that the it should be facilitated
with readily available to enable the staff entering the cubicle to put on sterile gowns
and masks separate gown for each cubicle.
 Cubicle partitions are used they should be made of shatter proof glass 7 feet high and
extends 7 feet from the wall.
 They should also be constructed to allow visibility by nurses and patients in the same
room.
 It is good to view all the patients from the same nurse‘s station.
INFECTION CONTROL IN A HOSPITAL
 Over the course of the past several years, the AIA (American Institute of Architects),
CDC (Centers for Disease Control), and JCAHO (Joint Commission for Accreditation
of Health Care Organizations ,As it turns out, the two best weapons for controlling
hospital is to manage air delivery systems and contaminant control responsibly and
In preventing the spread of contaminants during construction-related activities.
 The emphasis in managing a safe air quality environment during a construction in a
hospital or other health care facility.
 Design and construction of hospitals present many unique challenges, and the
complexity of maintaining a safe environment is certainly one of the most difficult.

46
SECURITY AND SAFETY:
In addition to the general safety concerns of all buildings, hospitals have several
particular security concerns:
 Protection of hospital property and assets, including drugs
 Protection of patients, including incapacitated patients, and staff
 Safe control of violent or unstable patients
 Vulnerability to damage from terrorism because of proximity to high-vulnerability
targets, or because they may be highly visible public buildings with an important role
in the public health system.
PUPLIC HEALTH EQUIPMENT
To estimate chorine demand of drinking water so that proper amount of bleaching
power may be added in drinking water storage tank of the hospital.
CHLOROSCOPE
To estimate residual chlorine in the matter treated by chlorine so that quality of
chlorination is assured.
FIRE PROTECTION:
Fire extinguishers 240 kg carbon dioxide type tested for each 1976 square space, with
central alarming indicator or centralized bell should be fitted in the whole hospital.
COMMUNICATION
Paging system, model spirit MK –II, beep and speech wireless selective paging
system.
GENERATOR
Capacity of 75 KVA 110 KV 2 grid system of 500 -700 beded hospital.
SANITATION AND DRAINAGE
Drainage system should directly be fitted with municipal pipe hospital, drainage pipe
should be around 12 inch and municipal pipe should be around 36 inch.
WATER TREATMENT AND SUPPLY:
There should be three stainless steel high level tanks for storing water (capacity: 3
core gallons) stored water should pass through filtration tank. Then it should get stored in
clear water well.chorination of water should be done. Then it should go to overhead tank.
BIOMEDICAL WASTE MANAGEMENT:
Followed as the rules given by the govt.

47
TIOLET ROOMS
LONG TERM CARE FACILITIES:
 At least 50 percent of patient toilets and bedrooms; all public use, common use or
areas which may result in employment of handicapped persons.
 Outpatient Facilities: All patient toilets and bedrooms, all public use, common use, or
areas which may result in employment of physically handicapped persons.
HOSPITAL:
 General Purpose Hospital:
 At least 10 percent of toilets and bedrooms, all public use, common use, or areas
which may result in employment of physically handicapped persons.
 Special Purpose Hospital:
 (Hospitals that treat conditions that affect mobility). All patient toilets bedrooms, all
public use, common use, or areas which may result in employment of physically
handicapped persons.
Toilet rooms.
Where alterations to existing facilities make strict compliance with 4.22 and 4.23
structurally impracticable, the addition of one "unisex" toilet per floor containing one water
closet complying with 4.16 and one lavatory complying with 4.19, located adjacent to
existing toilet facilities, will be acceptable in lieu of making existing toilet facilities for each
sex accessible.
TOILET STALLS
LOCATION. Accessible toilet stalls shall be on an accessible route and shall meet the
requirements of WATER CLOSETS: Water closets in accessible stalls .
SIZE AND ARRANGEMENT.
Toilet stalls with a minimum depth of 56 in (1420 mm) (see Fig. 30(a)) shall have
wall-mounted water closets. If the depth of toilet stalls is increased at least 3 in (75 mm), then
a floor-mounted water closet may be used. Arrangements shown for stalls may be reversed to
allow either a left- or right-hand approach
URINALS
HEIGHT.
Urinals shall be stall-type or wall-hung with an elongated rim at a maximum of 17 in
(430 mm) above the floor.

48
CLEAR FLOOR SPACE.
A clear floor space 30 in by 48 in (760 mm by 1220 mm) shall be provided in front of
urinals to allow forward approach. This clear space shall adjoin or overlap an accessible route
and shall comply with 4.2.4. Urinal shields that do not extend beyond the front edge of the
urinal rim may be provided with 29 in (735 mm) clearance between them.
FLUSH CONTROLS.
Flush controls shall be hand operated or automatic, and shall comply with 4.27.4, and shall be
mounted no more than 44 in (1120 mm) above the floor.
The ADA act
The Americans with Disabilities Act (ADA) is a law that prohibits discrimination against
people with disabilities, including deaf and hearing impaired people.
In general, the ADA expects hospitals and medical service providers to eliminate
anything that discriminates against a deaf person. Naturally, the foremost source of
discrimination against deaf people occurs as some form of communication. The ADA
requires communication that is effective and provides aids that are appropriate in
communicating with a deaf patient. Deaf patients must be able to communicate with doctors,
nurses, admission staff, and other hospital workers.
 The medical facility must be prepared to honor the deaf patient's request. Further, the
deaf patient may NOT be charged for expenses incurred in complying with ADA
requirements.
Standards:
The NFPA publishes the Codes and Standards CMS uses in determining compliance with
the fire safety requirements of our regulations. NFPA 80 5.2.4.requires the following items
shall be verified, at minimum:
 No Open Holes or breaks exist in surfaces of either the door or frame.
 Glazing, vision light frames & glazing beads are intact and securely fastened in place,
if so equipped.
 The door, frame, hinges, hardware, and noncombustible threshold are secured,
aligned, and in working order with no visible signes of damage.
 No parts are missing or broken.
 Door clearances at the door edge of the door frame, on the pull side of the door, do
not exceed clearances listed in 4.8.4 (the clearance under the bottom of the door shall
be a maximum of 3/4") and 6.3.1 (top & edges 1/8")

49
 The self-closing device is operational; that is, the active door completely closes when
operated from the full open position.
 If a coordinator is installed, the inactive leaf closes before the active leaf.
 Latching hardware operates and secure the door when it is in the closed position.
 Auxiliary hardware items that interfere or prohibit operation are not installed on the
door or frame.
 No field modifications to the door assembly have been performed that void the label.
 Gasketing and edge seals, where required, are inspected to verify their presence and
integrity.
 According to building and fire codes, annual fire door inspections is the responsibility
of the building owner. However, as with other mandatory fire inspections, such as the
inspection of fire dampers, the fire door inspections are often omitted and many
facilities are out of complianceThe final say on the acceptance of any inspection
requires the approval of the AHJ (Authority Having Jurisdiction).
SUPPLIES AND EQUIPMENT
INTRODUCTION
Supplies are those items that are used up or consumed; hence the term consumable is
used for supplies. The supplies in hospital include drugs, surgical goods (disposables, glass
wares), chemicals, antiseptics, food materials, stationeries, the linen supply etc. The term
equipment is used for more permanent type of article and may be classified as fixed and
movables. Fixed equipment is not a structure of the building, but it is attached to the walls or
floors (egg; steriliser,) Movable equipment includes furniture, instruments etc.
IMPROPER SUPPLIES:
In the most of the hospital and other health institutions no standard has been followed
in the supply of drugs are causing reactions and sometimes causing death for which no
reasons nurses made victims on so many occasions.so it is always better to supply standard
drugs.
For the comfort and the other aspects of patients there is need to change to change
linen everyday.in the real sense sometime it is not practicable due to dhobi system. The nurse
must incharge of maintenance of linen ,and equipments.toreplace or repair or make
condemnation of unserviceable line and other equipment ,the present procedure very very
strict.
And other way that the missing of instrument also nurses become a victim and
reducing amount from their monthly salary.

50
Medical Equipment that Every Healthcare Facility Must Have
Healthcare facilities include, but aren‘t limited to, nursing homes, hospitals, and out-
patient surgery centers. There are many health and safety hazards associated with these
places. The potential hazards include exposure to dangerous airborne germs and viruses,
exposure to bodily wastes and fluids, among others. This is why there is certain medical
equipment that every healthcare facility should have on hand. Important Medical
Equipment for Healthcare
Facilities:
Every Health Care Facility Should Have The Minimum And The Basic Requirements
And The medical equipment that‘s good to have at healthcare facilities such as nursing
homes and hospitals.
Wheelchair.
The wheelchair is a very popular piece of medical equipment. Wheelchairs are used
quite often in the daily operations of many healthcare facilities. They‘re not only used for
people who can‘t walk, but they‘re also used to transport patients from one place to the next.
Although automatic wheelchairs are available, healthcare facilities always use manual
wheelchairs.
Blood pressure monitor
This is necessary to check a person‘s blood pressure. It‘s also used quite often in
healthcare facilities. Depending on the size of the facility, more than one blood pressure
monitor will be needed. If you‘re using it for home care, you may only need one. There are
two types of blood pressure monitors: manual and automatic.
Gauze, tape, and bandages.
These are used to care for burns, cuts, bruises, sprains, and breaks. No healthcare
facility should be without a large supply.
Bedpans and urinals.
These allow bedridden patients to use the bathroom without needing to be moved.
Latex and vinyl gloves
(sterile and non-sterile). These help protect hands from being exposed to dangerous germs
and bodily fluids. They also help reduce the chances of cross-infecting patients. These gloves
aren‘t reusable, and should be disposed of following use.
Thermometers.
The thermometer is also an important piece of medical equipment. It‘s often necessary to get
a temperature reading, and you can‘t do it without a reliable thermometer.
Disinfectants.

51
It‘s important to keep the facility and yourself as clean as possible. Disinfectants to have are
hand sanitizer, antibacterial soap, antibacterial wipes, sprays, and cleaning and sterilizing
solutions.
Braces, crutches, medical collars, and splints.
These items have different purposes, and are a must have for all healthcare facilities.
CPR equipment and heart monitors.
These are vital pieces of equipment. Healthcare facilities should have enough
equipment for more than one patient at a time.
This list isn‘t all inclusive. There are many more pieces of medical equipment that
healthcare facilities should have. The purpose of this article is to provide a basic overview of
the type of medical equipment any well-equipped healthcare facility should have. Of course,
the type of equipment you need may depend on the type of care you provide. However, there
are some pieces of equipment that are generally needed for most healthcare facilities.
ISO Standards for Hospitals
Hospitals worldwide adhere to ISO-established safety parameters:
Non-surgical gloves must meet ISO standards as well.
ISO 11193: 2008 pertains to hospital gloves that a health care professional would use
in handling contaminated medical materials. ISO 11193:2008 has two sections and concerns
the bulk storage and packaging requirements for non-surgical gloves; it does not cover the
safe and proper usage of examination gloves. Part one concerns packaging and bulk storage
while part two concerns gloves intended for use in diagnostic or therapeutic procedures with
the goal of protecting patients from cross-contamination
Powdered Rubber Medical Gloves:
Some hospital gloves use skin powder to reduce hand irritation.ISO 21171:2006
describes standards for the presence of removable powder on the surface of medical gloves.
There are three methods: Method A pertains to powdered gloves and Methods B and C for
powder-free gloves. The standard does not address safety issues that may be associated with
powdered gloves, nor does it prescribe limits on the amounts that may be present
Medical Face-Mask Quality:
ISO 22609:2004 addresses a laboratory testing method which measures how
effectively medical face masks resist penetration by a splash of synthetic blood. The standard
primarily concerns the performance of materials from which the masks are manufactured and
does not address the mask's design, construction, interfaces or other factors which may affect
the overall protection. Hospitals worldwide adhere to ISO-established safetyparameters.:
The International Organization for Standardization (ISO) has several schedules that
hospitals follow in order to maintain their ISO certification. The standards cover surgical
gloves, medical gloves and even the wheels used on hospital beds. All ISO standards for

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